Mercatus Center : Healthcarehttps://www.mercatus.org/taxonomy/term/725/feed
enUbers of Health Carehttps://www.mercatus.org/commentary/ubers-health-care
<p>People perpetually ask, “Which company will become ‘the’ Uber of health care?” As of March, one company announced its intention to at least become “an” Uber of health care. Appropriately, the company entering the fray is … Uber.</p>
<p>Ridesharing’s pioneer company has launched UberHealth. The new venture effectively grafts its core business onto health care by providing transportation for patients to appointments at doctors’ offices, hospitals, clinics and rehab centers. The service differs from Uber’s familiar ridesharing business in that the medical providers will arrange the rides. The patient/passengers will not need the UberHealth app, and they won’t even need a smartphone.</p>
<p>UberHealth’s specific service could conceivably contribute as much to Americans’ health as a new drug or surgical procedure. American patients have a high no-show rate for medical appointments (one-third, according to Uber). Wasted appointment times cost providers money, which, like other operating expenses, gets passed on to all of us.</p>
<p>More important, a no-show can also mean that the patient forgoes important care or fails to follow through on regimens previously prescribed by providers. Actually making it to scheduled appointments has the potential to save lives and reduce suffering.</p>
<p>UberHealth hopes to cut into this absenteeism by lowering the costs and difficulty — for patients and providers — of shuttling to and from appointments. Potentially, UberHealth and similar services can also reduce the frivolous use of ambulances as ultra-expensive taxicabs.</p>
<p>This, of course, is a far cry from becoming “the” Uber of health care. But it’s unrealistic to expect any one firm to do for the whole of health care — one-fifth of the U.S. economy — what Uber did for a tiny slice of the considerably smaller transportation sector.</p>
<p>Uber injected new competition into a stodgy, protected market. But an important component of its success was the fact that the firm took aim at a fairly homogeneous line of business. Taxis ferry passengers from Point A to Point B, and usually over fairly small distances. Uber accumulated massive volumes of data, built superb telemetry, and built several levels of artificial intelligence to improve the experience of arranging a ride. But the key was finding one thing and doing it well.</p>
<p>Now, UberHealth seems to have zeroed in on a narrow sliver of health care where the status quo, as was the case with taxis, is less than ideal and amenable to a technological fix. Other Uber-like firms are doing the same. GetHeal.com, for example, enables patients to summon doctors to their homes or workplaces just as Uber users summon rides. LemonaidHealth.com simplifies the task of obtaining certain prescription drugs. DoctorOnDemand.com brings medical care to the home via laptop, tablet or smartphone. Opternative.com measures patients for eyeglasses via laptop and smartphone.</p>
<p>A common theme of “Uber-like” technologies is the combination of big data, connectivity and artificial intelligence to shrink transaction costs and shorten learning curves. Uber passengers can summon rides in seconds without searching for a phone number or a taxi stand. Uber drivers can effortlessly navigate the streets of cities they have never before visited. The technologies effectively amplify and accelerate the human brain.</p>
<p>The enormous size of our health care system, coupled with its many shortcomings, suggests room for hundreds of Uber-like enterprises. It will be interesting to see how many of these start-ups adopt another key feature of the Uber story — a willingness to push the limits of existing laws and regulations. For many decades, the taxi industry used its political muscle to stave off potential competitors in the business of intracity transport. Uber barreled through those obstacles, at times practicing what my colleague Adam Thierer calls “technological civil disobedience.”</p>
<p>This “let them sue us” attitude enabled Uber to overcome the barricades the taxi industry had worked assiduously for decades to construct. AirBNB did the same for the hospitality industry.</p>
<p>Health care is loaded with such artificial, deeply entrenched barriers. The real question is how many of the innovators with ideas as novel as Uber’s business model will also have the stomach to fend off the established players and their political agents.</p>
Tue, 03 Apr 2018 14:53:25 -0400Robert Graboyeshttps://www.mercatus.org/commentary/ubers-health-careSolving the Healthcare Workforce Supply Problemhttps://www.mercatus.org/bridge/podcasts/03272018/solving-healthcare-workforce-supply-problem
<p>Recently, Dr. Jeffrey S. Flier, distinguished service professor and former dean of the faculty of medicine at Harvard University, joined <a href="https://www.mercatus.org/leck-shannon">Leck Shannon</a>, healthcare program manager for the Mercatus Center, to talk about his recent work with <a href="https://asp.mercatus.org/jared-rhoads">Jared Rhoads</a> on <a href="https://www.mercatus.org/publications/us-health-provider-workforce">The US Health Provider Workforce</a>.</p>
<p>We started by discussing what Dr. Flier calls “the supply side” of the healthcare workforce. In other words, we talked about how many healthcare providers there are, and how they are educated, trained, and licensed.</p>
<p>That matters, because the number and type of healthcare providers can determine a host of other healthcare outcomes. Dr. Flier pointed to shortages in the supply of providers, both because an aging population will require more healthcare providers, and because the health provider workforce is, itself, aging.</p>
<p><strong>Highlights</strong></p>
<ul><li>Shannon and Dr. Flier discuss the “iron triangle” of healthcare, identifying ways in which improving the healthcare provider workforce can help reduce costs, improve quality, and expand access.</li>
<li>Dr. Flier explains the history of the accreditation process for medical schools in America, and points out how the current system could hamper innovation.</li>
<li>Dr. Flier points out the challenges faced by foreign medical graduates seeking employment in the US, and how improving their path to US healthcare careers could help address the shortage in the health provider workforce.</li>
</ul><p>Download this episode and subscribe to the Mercatus Policy Download on <a href="https://itunes.apple.com/us/podcast/mercatus-policy-download/id1359147968?mt=2">iTunes</a> or wherever you listen to your favorite podcasts.</p>
Tue, 27 Mar 2018 12:02:34 -0400Jeffrey S. Flier, Leck Shannon, Chad Reesehttps://www.mercatus.org/bridge/podcasts/03272018/solving-healthcare-workforce-supply-problemRobert Graboyes on NPR&#039;s 1Ahttps://www.mercatus.org/podcasts/03142018/robert-graboyes-nprs-1a
<p>Robert Graboyes discusses right to try legislation with host Joshua Johnson and guests.</p>
<p> </p>
Wed, 14 Mar 2018 16:16:46 -0400Robert Graboyeshttps://www.mercatus.org/podcasts/03142018/robert-graboyes-nprs-1aCan States Repair the ACA&#039;s Damage?https://www.mercatus.org/commentary/can-states-repair-acas-damage
<p>Having failed to repeal the Affordable Care Act, congressional Republicans now want to create a new <a href="http://www.nationalreview.com/article/456067/obamacare-gop-republicans-prepare-back-bailout">corporate welfare program</a> to save it.</p>
<p>Here’s a better idea: Congress and the administration should give states more latitude to clean up the mess — at no additional cost to the federal government.</p>
<p>That is a central recommendation of a new <a href="https://www.mercatus.org/publications/affordable-care-act-individual-markets-state-innovation">Mercatus Center study</a> that we co-authored. Our study examined congressional and federal proposals that surfaced throughout last year in the broader context of the star-crossed “repeal and replace” debate.</p>
<p>The most promising ideas to repair broken insurance markets emanated not from Washington, but from the states.</p>
<p>That should surprise no one. States have traditionally been the primary regulators of health insurance, as they are for other forms of insurance. Obamacare rests on the hubris that federal bureaucrats could regulate health-insurance markets better than could states.</p>
<p>Federal intervention has proven a mixed blessing or a mixed curse, depending on your point of view. Insurance coverage is more accessible to those with chronic medical conditions who don’t have employer-sponsored insurance and don’t qualify for Medicare or Medicaid. More low-income people have insurance today than in 2013. If you spend <a href="https://www.cbo.gov/sites/default/files/recurringdata/51298-2017-09-healthinsurance.pdf">$1.8 trillion</a> on Medicaid expansions and subsidies, you’re bound to help some.</p>
<p>But others are hurting. Premiums for non-group coverage <a href="https://www.hhs.gov/about/news/2017/05/23/hhs-report-average-health-insurance-premiums-doubled-2013.html">more than doubled</a> between 2013 (the year before Obamacare took effect) and 2017 and increased by another <a href="http://money.cnn.com/2017/10/26/news/economy/obamacare-premiums-open-enrollment/index.html">37 percent</a> this year. Consumers, like many insurers, have responded by abandoning those markets. The individual market <a href="http://www.nationalreview.com/article/450310/obamacares-secret-coverage-losses">began to shrink</a> in 2016, a contraction that appears to have accelerated last year.</p>
<p>Yet the green shoots of state innovation continue to sprout from Obamacare’s ruins. The question is whether Washington will nurture or uproot them.</p>
<p>Our study chronicles how federal legislative efforts to repeal Obamacare gradually evolved to allow more state control over how federal resources would be directed and more latitude to deviate from the law’s stultifying regulatory regime.</p>
<p>At the same time, the Trump administration <a href="https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Downloads/March-13-2017-letter_508.pdf">encouraged states</a> to take full advantage of an obscure <a href="https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Section_1332_State_Innovation_Waivers-.html">provision</a> of the Obamacare statute that permits the Centers for Medicare and Medicaid Services to grant waivers to states to sidestep some of the law’s most onerous requirements.</p>
<p>States responded aggressively to the administration’s overtures. A number of proposals emerged, each of which set forth cutting-edge ways to make health insurance more affordable, especially to those who don’t qualify for federal subsidies.</p>
<p>Most importantly, states had to show that their waivers wouldn’t result in additional federal spending. Instead, their programs had to allocate federal dollars more efficiently, reducing premiums and, as a consequence, federal premium-assistance subsidies, holding the federal government harmless.</p>
<p>Alaska, unlike other states, won federal approval for its “reinsurance” waiver. They finance it partially with state funds and partially with federal money that would otherwise have been paid directly to insurers on behalf of low-income enrollees. The results are promising. Premiums for the lowest-priced Bronze plan in the state fell by <a href="https://www.heritage.org/sites/default/files/2017-12/IB4797.pdf">25 percent</a> in 2018. In other states, premiums for such plans rose by a median of 16.4 percent.</p>
<p>Congressional Republicans are learning the wrong lessons from Alaska. The insurance lobby has convinced GOP lawmakers that state reinsurance programs would work even better if they weren’t budget-neutral to the federal government. The more the feds <a href="http://health.oliverwyman.com/transform-care/2018/02/the_affordable_care.html">spend</a>, lobbyists argue, the more consumers will save.</p>
<p>Our study suggests that giving states more control over their markets (rather than more money for insurance companies) is the far better path. Allowing them more latitude to deviate from the ACA’s stringent structure can help make insurance more affordable, while still protecting consumers.</p>
<p>Unfortunately, many states are feeling burned. The Trump administration invited them to innovate, then declined to approve many of their innovative proposals. The administration should restore that trust by rescinding Obama-era guidelines that impose counterproductive limitations on waivers and taking additional steps to streamline the waiver approval process.</p>Tue, 06 Mar 2018 17:01:53 -0500Doug Badger, Rea S. Hederman Jr.https://www.mercatus.org/commentary/can-states-repair-acas-damageStabilizing the ACA’s Individual Marketshttps://www.mercatus.org/publications/affordable-care-act-individual-markets-state-innovation
<p>Through its regime of subsidies, penalties, and federal regulations, the Affordable Care Act (ACA) made health insurance affordable to millions of people who were uninsured because they earned too little or had preexisting conditions. But it also made insurance more expensive for millions who used to be able to afford it. Between December 2013 and January 2017, average premiums more than doubled, and individual markets were in turmoil.</p>
<h3>How can Washington most effectively address this problem and improve health insurance markets?</h3>
<p>That’s the question Doug Badger and Rea S. Hederman Jr. seek to answer. Given the failure to pass legislation to repeal and reform the ACA, Con­gress and the administration should empower states to devise new ways to make health insurance more affordable for more people. The means to do that is through the flexibility provided by section 1332 of the ACA.</p>
<p>Section 1332 authorizes the secretary of Health and Human Services (HHS) to grant states waivers from certain ACA regulatory requirements. The provision enables states to deploy existing federal resources in a more cost-effective way, without the need for new spending.</p>
<p>Most innovation waivers that have been filed seek to redirect federal subsidies from individuals to a reinsurance plan that can reduce premiums. But these waivers have been difficult to obtain under the Obama-era HHS guid­ance, and some states have withdrawn their requests because of the length of the waiver process. To date, only two waivers have been formally approved (Hawaii and Alaska).</p>
<h3>Why is stabilizing individual markets through state innovation a good idea?</h3>
<ul><li>Uniform federal rules have yielded disparate results, with some states tolerating the ACA’s regulatory regime better than others. Congress should recognize the primary role of states (not the federal govern­ment) in restoring order to their individual markets.</li>
<li>In addition to variations among states, there are variations within each state. For example, rural counties are often less able to attract insurers willing to offer coverage at affordable rates. States are better posi­tioned than federal policymakers to address these issues.</li>
<li>States can more effectively direct federal resources in order to lower premiums in the individual insur­ance market for those who are ineligible for subsidies.</li>
<li>Section 1332 removes the need for Congress to allocate additional federal money to stabilize individual insur­ance markets. States can use the waiver process to reduce market turbulence without increasing federal spending.</li>
</ul><p>To succeed, the administration should streamline and improve the ACA waiver process. It should issue new guid­ance that is less restrictive than the Obama-era guidance and encourage an expedited process.</p>
Tue, 27 Feb 2018 09:00:28 -0500Doug Badger, Rea S. Hederman Jr.https://www.mercatus.org/publications/affordable-care-act-individual-markets-state-innovationRestoring Vision to Consumers and Competition to the Marketplacehttps://www.mercatus.org/publications/restoring-vision-consumers-competition-marketplace-required-prescription-release
<p>Patients who use contact lenses need a prescription from an optometrist. Until recently, optometrists could withhold prescriptions from consumers and force them to purchase contact lenses from the optometrist. Locking in patients after examining their vision may have enabled optometrists to charge higher prices for contact lenses and earn higher salaries.</p>
<p>Edward J. Timmons and Conor Norris find that giving patients more choices about where to buy their contact lenses by requiring optometrists to release prescription information to patients reduces optometrist wages by 10 percent.</p>
<h3>Fairness to Contact Lens Consumers Act</h3>
<p>The federal Fairness to Contact Lens Consumers Act (FCLCA) of 2004 requires vision service providers to release prescription information. This statute enhances the ability of patients to comparison-shop for their contact lenses.</p>
<h3>State Regulation of Contact Lens Prescriptions</h3>
<p>Some states had passed similar laws before 2004, led by Ohio in 1978. Most states followed suit in the next two decades. Fifteen states and the District of Columbia implemented the change in 2004 along with the FCLCA: Alaska, Connecticut, Hawaii, Illinois, Mississippi, Missouri, Montana, Nevada, New Mexico, North Dakota, Pennsylvania, Rhode Island, South Carolina, Tennessee, and West Virginia.</p>
<p>Key Findings</p>
<ul><li>The FCLCA increased competition, allowing consumers to purchase contact lenses from vision professionals, brick-and-mortar retail stores, or online outlets. This has resulted in lower wages for optometrists.</li>
<li>Requiring optometrists to share prescriptions allowed consumers to search out lower-cost alternatives for their lenses.</li>
<li>Legislation similar to the FCLCA may prove to be effective at lowering costs in other markets, such as medical services. Medical professionals could recommend tests and minor procedures, and the tests could be performed outside the medical provider’s office, potentially at a lower cost to the patient.</li>
<li>Lawmakers should maintain the intent of the FCLCA, which provides more competition in the marketplace and better serves the needs of contact lens users.</li>
</ul><p>Requiring optometrists to release prescription information to patients may have made consumers better off, with increased competition in the contact lens market.</p>
Tue, 27 Feb 2018 17:22:48 -0500Edward J. Timmons https://www.mercatus.org/publications/restoring-vision-consumers-competition-marketplace-required-prescription-releaseWhy the U.S. Needs More Doctors Trained Abroadhttps://www.mercatus.org/commentary/why-us-needs-more-doctors-trained-abroad
<p>In the U.S. today, 23% of practicing physicians, or about 240,000, are graduates of international medical schools, and these “IMGs” make up a similar percentage of those in graduate medical training programs. We need more of them.</p>
<p>Even with those practitioners added to graduates of U.S. schools, we have an insufficient medical workforce today to address the nations’ needs—a shortage predicted to grow as the population ages. Easing the barriers to attract more internationally trained physicians is essential to keep our health-care system staffed with the right kind of doctors. There are three key arguments for bringing more internationally trained doctors to the U.S.</p>
<p><a href="https://blogs.wsj.com/experts/2018/02/27/why-the-u-s-needs-more-doctors-trained-abroad/">Continue reading</a></p>
Tue, 06 Mar 2018 16:46:11 -0500Jeffrey S. Flierhttps://www.mercatus.org/commentary/why-us-needs-more-doctors-trained-abroadHow Can We Remedy the Shortage of Health Providers?https://www.mercatus.org/commentary/how-can-we-remedy-shortage-health-providers
<p>In a medical mecca like Boston, which is home to three medical schools and many world-class hospitals, you’d think that getting a timely appointment with a primary care physician or specialist would be a breeze. It isn’t. Finding a doctor is even harder in rural and underserved areas. Yet the public debate on health care remains focused on insurance and funding, and largely ignores the undersupply of health care professionals. Access to care means more than adequate insurance.</p>
<p>Many factors influence projections about the size of the health provider workforce, which have swung widely over past decades. How best to assess it, from average wait times for appointments to number of physicians per population (both of which vary geographically and by specialty), is still an open question.</p>
<p>That said, it is clear that the growth and aging of the U.S. population combined with an aging physician workforce translates into a <a href="https://www.statnews.com/2017/08/28/freelance-contract-physicians/">need for more providers</a>. The Association of American Medical Colleges has recently predicted a nationwide shortage of somewhere between <a href="https://news.aamc.org/medical-education/article/new-aamc-research-reaffirms-looming-physician-shor/">40,800 and 104,900 physicians</a> by 2030.</p>
<p>Ironically, one of the biggest obstacles to improving access to health care providers is the profession itself, enabled by a plethora of public and private agencies that control licensing and certification. These often inadvertently limit access to care rather than enhance it.</p>
<p>The current system for training doctors dates to the early 20th century, when <a href="https://www.basicbooks.com/titles/paul-starr/the-social-transformation-of-american-medicine/9780786725458/">medicine transitioned</a> from a largely ineffective and amateurish enterprise to one rooted in science. Physician training and licensing have certainly evolved since then, but at a disappointingly slow pace. Physician shortages are increasing as the population ages, while many enthusiastic and capable students and trained foreign-born caregivers are shut out of the profession.</p>
<p>Why has so little attention been paid to the number and quality of health care providers? Physician education, licensing, and credentialing are determined by an alphabet soup of organizations that change at a glacial pace. Their roles and interactions are difficult to delineate, even for a former dean of Harvard Medical School, and this complexity makes change difficult.</p>
<p>Worse, while the mission statements of these licensing organizations stress public health, they also serve the interests of incumbent professionals, who may be wary of new competitors. Tension between these conflicting interests produces a less innovative, less diverse, and less accessible workforce than could be the case.</p>
<p>Accreditation is regulated by the <a href="https://www.aamc.org/members/osr/committees/48814/reports_lcme.html">Liaison Committee on Medical Education</a>, a body sponsored by the Association of American Medical Colleges and the American Medical Association and recognized by the Department of Education for accrediting programs leading to the M.D. degree. It manages a rigorous process that, despite many benefits, raises the bar too high for creating new medical schools and slows the rate of educational innovation.</p>
<p>After completing medical school, graduates must pass a three-part exam and complete a one-year internship to become eligible for state licensing. Most physicians undertake further clinical training and specialization in hospitals, overseen by other certifying organizations. Hospital committees conduct evaluations before granting admitting privileges to carry out specific procedures or tasks.</p>
<p>Medical standards are essential. Can we develop more efficient approaches to ensuring them?</p>
<p>As my colleague Jared Rhoads and I <a href="https://www.mercatus.org/publications/us-health-provider-workforce">argue in a white paper</a> on the U.S. health provider workforce, the key is to substitute competency-based assessments for the process-driven approaches used today. Some costly exams and recertification processes have little or no evidence to support their use. Which schools a doctor has attended or exams she has passed matter far less than her competence. And please don’t misconstrue finding new ways to train and certify competent providers as lowering standards or expectations for quality — it’s quite the opposite.</p>
<p>The number of U.S. medical schools and the size of each year’s class have increased over the past decade, but not enough to solve the pressing workforce issue. Nearly a quarter of currently licensed physicians — well over 200,000 — are foreign trained, and the care they provide equals that of graduates of U.S. medical schools. They disproportionately <a href="https://www.statnews.com/2017/02/07/trump-iraq-refugee-doctor/">practice in rural</a> and underserved communities. Why not increase their numbers?</p>
<p>The <a href="https://www.ecfmg.org/">Educational Commission for Foreign Medical Graduates</a> certifies international medical graduates from legitimate medical schools, regulates access to the same exams that U.S. grads must pass, and authorizes the residencies required for licensing. But many more foreign medical graduates are eligible for residency positions in U.S. hospitals than there are available slots for them.</p>
<p>If training slots are limited, why not allow fully trained foreign physicians to fill the void? Under current rules, to secure a license they must repeat in U.S. hospitals the residencies and fellowships they already completed in their home countries. Many outstanding doctors will not do this. It would not be difficult to design a system through which hospitals and other health organizations facilitate and take responsibility for physician relocation.</p>Thu, 22 Feb 2018 15:33:21 -0500Jeffrey S. Flierhttps://www.mercatus.org/commentary/how-can-we-remedy-shortage-health-providersThe US Health Provider Workforcehttps://www.mercatus.org/publications/us-health-provider-workforce
<p>Today’s health policy debates tend to focus on insurance coverage and payment systems—the “demand side” of healthcare. Just as important (though often neglected) are the factors that determine the number of licensed practitioners—the “supply side.” New approaches to the education, training, licensing, and certification of medical professionals (including the use of new technologies) can significantly improve access, cost, and quality of care for Americans.</p>
<p>Jeffrey S. Flier and Jared M. Rhoads make this argument. They also point out the challenges to reform: the credentialing of medical practi­tioners within the state-based regulatory system is controlled by a myriad of professional “gatekeeper” organizations that use their monopoly positions to protect their members from local and international competition.</p>
<p>These organizations tend to be cautious, conservative, and nontransparent as a result. Accordingly, Flier and Rhoads make the following recommendations to improve the education, training, licensing, and certification of high-quality medical professionals.</p>
<ul><li><i>New schools, more doctors.</i> Remove barriers to creating new accredited US schools and training positions for physicians. This includes developing shorter and less expensive training paths.</li>
<li><i>More foreign-trained physicians</i>. Provide paths to licensure that do not require retraining for qualified interna­tional medical graduates who have completed advanced clinical training in their home countries. These physicians are substantially more likely to practice in rural and poorer communities and in much-needed primary care specialties.</li>
<li><i>Use of nonphysician providers</i>. Expand the type of care that can be provided by (less costly) physician assis­tants and nurse practitioners, who perform many primary care services as safely and effectively as physicians. This can help mitigate physician shortages in underserved parts of the country.</li>
<li><i>Transformative new technologies</i>. Embrace the use of telemedicine, physiologic sensors, mobile health apps, and other potential “force multipliers”—for both medical education and practice. This can increase the number of health providers, raise their productivity, and offer greater convenience to patients.</li>
</ul><p>The physician shortage is likely to worsen even as the population ages and requires increasing levels of care. Phy­sicians as a group are aging, too, and are working fewer hours. In addition, the Medicaid expansion under the Affordable Care Act has extended coverage to millions of previously uninsured individuals now seeking care. Given these realities, reforms in the medical profession are needed to improve access to services, quality of care, and outcomes for patients.</p>
Tue, 20 Feb 2018 09:01:07 -0500Jeffrey S. Flier, Jared Rhoadshttps://www.mercatus.org/publications/us-health-provider-workforceFrom Electronic Health Records to Digital Health Biographieshttps://www.mercatus.org/publications/electronic-health-records-ehr-digital-health-biographies
<p>For medical providers, traditional paper records of patient encounters have been giving way to electronic health records (EHRs, sometimes called electronic medical records or EMRs). EHRs are widely touted as a critical tool for lowering healthcare costs and improving quality. In fact, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provides financial support for medical providers’ transition to EHRs.</p>
<p>Unfortunately, there is widespread sentiment that today’s EHRs actually increase costs and detract from the quality of healthcare. Tending to EHRs may occupy more than half the time of a typical primary care visit, interfering repeatedly with the doctor’s concentration and eroding doctor-patient rapport.</p>
<p>Robert F. Graboyes, PhD, and Darcy N. Bryan, MD, review how today’s EHRs have failed to improve healthcare. More significantly, they offer an alternative vision that reimagines EHRs as “digital health biographies” (DHBs) that both empower patients and assist providers. To achieve this vision, EHRs should be allowed to develop as the internet did during the 1990s: according to a model of permissionless innovation rather than one of preemptive regulation.</p>
<h3>Digital Health Biographies</h3>
<p>EHRs of the future need not resemble those of today. A system of digital health biographies would provide two important benefits:</p>
<ul><li>By bringing together health data from many different sources, a DHB would be a more complete, accurate picture of each person’s health—equipping both patients themselves and their healthcare providers with compact, coherent, and targeted information.</li>
<li>The DHB system would aggregate the data of myriad individuals, giving researchers a previously unavailable opportunity to analyze the factors that contribute to health and sickness.</li>
</ul><p>Graboyes and Bryan offer the following general principles regarding the structure, ownership, and uses of DHBs. These principles provide a starting point for policymakers, developers, and medical providers striving to fulfill the theoretical promise of EHRs:</p>
<ol><li>Patients should own their individual DHB and its data.</li>
<li>Each patient should have precisely one DHB.</li>
<li>A patient’s DHB should incorporate data from multiple providers.</li>
<li>The DHB should also incorporate data from wearable telemetry such as Fitbits, insulin pumps, and heart monitors.</li>
<li>The DHB should incorporate subjective data entered by patients themselves.</li>
<li>To the greatest extent possible, data entry should use natural language (ordinary spoken or written sentences) rather than structured queries (such as drop-down menus).</li>
<li>Machine learning capabilities should extract and organize output for specific users.</li>
<li>Input and output should be recognized as different functions requiring different software.</li>
<li>A common protocol or protocols should be set up to minimize the cost and difficulty of shifting from one input or output vendor to another.</li>
<li>To maximize competition among vendors, the government should not mandate or subsidize any particular vendors or data requirements.</li>
<li>DHB usage should be voluntary on the part of healthcare providers so that the systems must continually prove their worth.</li>
<li>The dominant motivations for DHBs should be improved patient health and provider efficiency.</li>
</ol><h3>Questions for Future Research</h3>
<p>The 12 DHB principles offered above are aspirational; a comprehensive, viable set of principles will require further research to answer the following questions:</p>
<ul><li>How would patient ownership of health data affect its production and quality? For instance, if the data from devices such as Fitbits were incorporated into DHBs, would that reduce companies’ incentives to produce such data?</li>
<li>Should all health information be included in DHBs? (What’s the best way to ensure patients’ privacy?)</li>
<li>Is artificial intelligence capable of the sort of customized input and output that would be necessary for DHBs to work as envisioned? How should developers balance the benefits of being able to enter data in natural language with the benefits provided by highly structured data?</li>
<li>Who should have access to DHBs?</li>
<li>How much centralized control over data and communications protocols would be necessary in order to make DHBs “interoperable”—accessible to a wide variety of users and adaptable to a wide variety of functions?</li>
</ul>Thu, 15 Feb 2018 09:11:48 -0500Robert Graboyes, Darcy N. Bryan, MDhttps://www.mercatus.org/publications/electronic-health-records-ehr-digital-health-biographies